Harland Clarke Holdings Corp.: High Deductible Health Plan Coverage Period: 01/01/2013 to 12/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee, Employee + Spouse, Employee+Child(ren), Family | Plan Type: HDHP
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document
at www.bcbstx.com/harlandclarke or by calling (800)382-0818.
Important Questions
Answers
Why this Matters:
What is the overall
deductible?
In-Network
$1,500 Individual/ $3,000 Family
Out-Network
$3,000 Individual/$6,000 Family
Doesn’t apply to preventive care.
You must pay all the costs up to the deductible amount before this plan begins to pay for
the covered services you use. Check your plan document to see when the deductible starts
over (usually, but not always, January 1st). See the chart starting on page 2 for how much you
pay for covered services after you meet the deductible.
Are there other
deductibles for specific
services?
No.
You don’t have to meet deductibles for specific services but see the chart starting on page 2
for other costs for services this plan covers.
Is there an out–of–pocket
limit on my expenses?
Yes. In-network - $4,000
Individual/$8,000 Family
Out-of-network - $8,000
Individual/$16,000 Family
The out-of-pocket limit is the most you could pay during a coverage period (usually one
year) for your share of the cost of covered services. This limit helps you plan for health care
expenses.
What is not included in
the out–of–pocket limit?
Premiums, Balance-billed charges,
and health care this plan doesn’t
cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall annual
limit on what the plan
pays?
Yes. $2 million.
The amount the Plan will pay for essential Benefits during the plan year.
Does this plan use a
network of providers?
If you use an in-network doctor or other health care provider, this plan will pay some or all
of the cost of covered services. Be aware, your in-network doctor or hospital may use an outYes. For a list of network providers
of-network provider for some services. The Plan uses the term in-network, preferred, or
see bcbstx.com/harlandclarke
participating for providers in their network. See the chart starting on page 2 for how this
plan pays different kinds of providers.
Do I need a referral to see
a specialist?
No.
You can see the specialist you choose without permission from this plan.
Are there services this
plan doesn’t cover?
Yes.
Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan
document for additional information about excluded services.
Questions: Call (800)521-2227 or visit us at www.bcbstx.com/harlandclarke
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call the number above to request a copy.
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Harland Clarke Holdings Corp.: High Deductible Health Plan Coverage Period: 01/01/2013 to 12/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee, Employee + Spouse, Employee+Child(ren), Family | Plan Type: HDHP
 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.
 Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s


allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met
your deductible.
The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed
amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed
amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)
This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts.
Common
Medical Event
If you visit a health
care provider’s office or
clinic
If you have a test
Services You May Need
Your Cost If You Use
an
In-network Provider
Your Cost If You
Use an
Out-of-network
Provider
Limitations & Exceptions
Primary care visit to treat an injury or
illness
20% coinsurance
40% coinsurance
--------------------none---------------------
Specialist visit
20% coinsurance
40% coinsurance
--------------------none---------------------
Other practitioner office visit
20% coinsurance
40% coinsurance
Acupuncture and Naturopathic Services
up to $1,000; Chiropractic 20 visit limit.
Per calendar year per covered person.
Preventive
care/screening/immunization
No Charge
40% coinsurance
Includes preventive health services
specified in health care reform law.
Diagnostic test (x-ray, blood work)
20% coinsurance
40% coinsurance
--------------------none---------------------
Imaging (CT/PET scans, MRIs)
20% coinsurance
40% coinsurance
--------------------none---------------------
Questions: Call (800)521-2227 or visit us at www.bcbstx.com/harlandclarke
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call the number above to request a copy.
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Harland Clarke Holdings Corp.: High Deductible Health Plan Coverage Period: 01/01/2013 to 12/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Common
Medical Event
Services You May Need
Generic drugs
If you need drugs to
treat your illness or
condition
More information about
prescription drug
coverage is available at
www.express-scripts.com
If you have outpatient
surgery
If you need immediate
medical attention
If you have a hospital
stay
Preferred brand drugs
Non-preferred brand drugs
Coverage for: Employee, Employee + Spouse, Employee+Child(ren), Family | Plan Type: HDHP
Your Cost If You Use
an
In-network Provider
$15 copay (retail) after
deductible has been met,
except for generic
preventive drugs
$40 copay/(retail) after
deductible has been met
$80 copay/(retail) after
deductible has been met
Your Cost If You
Use an
Out-of-network
Provider
Not Covered
Not Covered
Limitations & Exceptions
Covers up to 30 day supply (retail); Mail
order copays are 2 ½ times the retail
amount for a 90 day supply
Not Covered
$90 mail order: Generic
$37.50; Preferred Brand
$100.00; Non-preferred
Brand $200, after
deductible has been met
Not Covered
Specialty drugs must go through
specialty mail order. Specialty drugs are
initially dispensed in 30 day supply (even
if the doctor writes a prescription for 90
days) to ensure tolerance and avoid
wastage. Mail order copays are 2 ½
times the retail amount for a 90 day
supply
Facility fee (e.g., ambulatory surgery
center)
Physician/surgeon fees
20% coinsurance
40% coinsurance
--------------------none---------------------
20% coinsurance
40% coinsurance
--------------------none---------------------
Emergency room services
20% coinsurance
20% coinsurance
--------------------none---------------------
Emergency medical transportation
20% coinsurance
20% coinsurance
--------------------none---------------------
Urgent care
20% coinsurance
40% coinsurance
--------------------none---------------------
Facility fee (e.g., hospital room)
20% coinsurance
40% coinsurance
Physician/surgeon fee
20% coinsurance
40% coinsurance
Prior Notification required for certain
covered health services
Specialty drugs
Questions: Call (800)521-2227 or visit us at www.bcbstx.com/harlandclarke
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call the number above to request a copy.
3 of 8
Harland Clarke Holdings Corp.: High Deductible Health Plan Coverage Period: 01/01/2013 to 12/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee, Employee + Spouse, Employee+Child(ren), Family | Plan Type: HDHP
Your Cost If You Use
an
In-network Provider
Your Cost If You
Use an
Out-of-network
Provider
Common
Medical Event
Services You May Need
20% coinsurance
40% coinsurance
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health outpatient
services
Mental/Behavioral health inpatient
services
Substance use disorder outpatient
services
Substance use disorder inpatient services
20% coinsurance
40% coinsurance
20% coinsurance
40% coinsurance
20% coinsurance
40% coinsurance
Prenatal and postnatal care
20% coinsurance
40% coinsurance
Delivery and all inpatient services
20% coinsurance
40% coinsurance
Home health care
20% coinsurance
40% coinsurance
Rehabilitation services
20% coinsurance
40% coinsurance
Habilitation services
20% coinsurance
40% coinsurance
Skilled nursing care
20% coinsurance
40% coinsurance
Durable medical equipment
20% coinsurance
40% coinsurance
--------------------none--------------------Prior Notification required for certain
covered health services
120 visits per calendar year. Prior
Notification required
120 visits of physical, occupational,
habilitation, and speech therapy
combined. 30 visits of pulmonary rehab
therapy. No visit limit for cardiac
rehabilitation therapy. Visit maximums
per calendar year.
120 days per calendar year. Prior
Notification required
--------------------none---------------------
Hospice service
20% coinsurance
40% coinsurance
Prior Notification required
Eye exam
No Charge
Not Covered
Vision screening only
Dental check-up
Not Covered
Not Covered
--------------------none---------------------
If you are pregnant
If you need help
recovering or have
other special health
needs
If your child needs
dental or eye care
Questions: Call (800)521-2227 or visit us at www.bcbstx.com/harlandclarke
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call the number above to request a copy.
Limitations & Exceptions
Prior Notification required for certain
covered health services
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Harland Clarke Holdings Corp.: High Deductible Health Plan Coverage Period: 01/01/2013 to 12/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee, Employee + Spouse, Employee+Child(ren), Family | Plan Type: HDHP
Excluded Services & Other Covered Services:
Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Cosmetic Surgery

Infertility Treatment

Routine Eye Care

Dental Care

Long Term Care

Routine Foot Care

Glasses

Private Duty Nursing

Weight Loss Programs
Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Acupuncture/Naturopathic services limited to
$1,000/year

Chiropractic Care limited to 20 visits/year

Bariatric Surgery (additional $1,000 copay per
admission)

Hearing Aids (as a result of accident only)

Non-emergency care when traveling outside
the U.S.

Organ and Tissue Transplant
Your Rights to Continue Coverage:
If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health
coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while
covered under the plan. Other limitations on your rights to continue coverage may also apply.
For more information on your rights to continue coverage, contact the plan at 1-800- 382-0818. You may also contact the U.S. Department of Labor, Employee
Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or
www.cciio.cms.gov.
Questions: Call (800)521-2227 or visit us at www.bcbstx.com/harlandclarke
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call the number above to request a copy.
5 of 8
Harland Clarke Holdings Corp.: High Deductible Health Plan Coverage Period: 01/01/2013 to 12/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee, Employee + Spouse, Employee+Child(ren), Family | Plan Type: HDHP
Your Grievance and Appeals Rights:
If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions
about your rights, this notice, or assistance, you can contact:
BlueCross and Blue Shield of Texas at 1 800-382-0818 or www.bcbstx.com
Express-Scripts at 1-800-753-2851 or fax 1-888-235-8551 or www.express-scripts.com
www.texashealthoptions.com or you may also contact the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or
www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.
Language Access Services:
[Spanish (Español): Para obtener asistencia en Español, llame al 1-800- 382-0818
[Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800- 382-0818
[Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800- 382-0818
[Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800- 382-0818
––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––
Questions: Call (800)521-2227 or visit us at www.bcbstx.com/harlandclarke
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call the number above to request a copy.
6 of 8
Harland Clarke Holdings Corp.: High Deductible Health Plan Coverage Period: 01/01/2013 to 12/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
About these Coverage Examples:
These examples show how this plan might cover
medical care in given situations. Use these
examples to see, in general, how much financial
protection a sample patient might get if they are
covered under different plans.
This is
not a cost
estimator.
Don’t use these examples to
estimate your actual costs
under this plan. The actual
care you receive will be
different from these
examples, and the cost of
that care will also be
different.
Coverage for: Employee, Employee + Spouse, Employee+Child(ren), Family | Plan Type: HDHP
Having a baby
Managing type 2 diabetes
(normal delivery)
(routine maintenance of
a well-controlled condition)
 Amount owed to providers: $7,540
 Plan pays $4,050
 Patient pays $ 3,490
Sample care costs:
Hospital charges (mother)
Routine obstetric care
Anesthesia
Hospital charges (baby*)
Laboratory tests
Prescriptions
Radiology
Vaccines, other preventive (plan pays
100%)
Total
 Amount owed to providers: $5,400
 Plan pays $2,210
 Patient pays $ 3,190
$2,700
$2,100
$900
$900
$500
$200
$200
$40
$7,540
Sample care costs:
Prescriptions
Medical Equipment and Supplies
Office Visits and Procedures
Education
Laboratory tests
Vaccines, other preventive (plan pays
100%)
Total
$5,400
Patient pays:
Deductibles
Copays (prescriptions)
Coinsurance
Limits or exclusions
Total
$1,500
$550
$160
$0
$2,210
Patient pays:
Deductibles
$2,400
See the next page for
Copays (prescription)
$110
important information about
these examples.
Coinsurance
$980
Limits or exclusions
$0
Total
$3,490
*Hospital charges for baby subject to family deductible if
added to the plan.
Questions: Call (800)521-2227 or visit us at www.bcbstx.com/harlandclarke
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call the number above to request a copy.
$2,900
$1,300
$700
$300
$100
$100
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Harland Clarke Holdings Corp.: High Deductible Health Plan Coverage Period: 01/01/2013 to 12/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage for: Employee, Employee + Spouse, Employee+Child(ren), Family | Plan Type: HDHP
Questions and answers about the Coverage Examples:
What are some of the assumptions behind
What does a Coverage Example show?
the Coverage Examples?
For each treatment situation, the Coverage
Example helps you see how deductibles,
 Costs don’t include premiums.
copayments, and coinsurance can add up. It
 Sample care costs are based on national
also helps you see what expenses might be left
averages supplied by the U.S. Department
up to you to pay because the service or
of Health and Human Services, and aren’t
treatment isn’t covered or payment is limited.
specific to a particular geographic area or
health plan.
Does the Coverage Example predict my
 The patient’s condition was not an excluded
own care needs?
or preexisting condition.
 All services and treatments started and
 No. Treatments shown are just examples.
ended in the same coverage period.
The care you would receive for this
 There are no other medical expenses for
condition could be different based on your
any member covered under this plan.
doctor’s advice, your age, how serious your
condition is, and many other factors.
 Out-of-pocket expenses are based only on
treating the condition in the example.
 The patient received all care from inDoes the Coverage Example predict my
network providers. If the patient had
future expenses?
received care from out-of-network
No. Coverage Examples are not cost
providers, costs would have been higher.
estimators. You can’t use the examples to
estimate costs for an actual condition. They
are for comparative purposes only. Your
own costs will be different depending on the
care you receive, the prices your providers
charge, and the reimbursement your health
plan allows.
Yes. When you look at the Summary of
Benefits and Coverage for other plans, you’ll
find the same Coverage Examples. When
you compare plans, check the “Patient Pays”
box in each example. The smaller that
number, the more coverage the plan
provides.
Are there other costs I should consider
when comparing plans?
Yes. An important cost is the premium you
pay. Generally, the lower your premium,
the more you’ll pay in out-of-pocket costs,
such as copayments, deductibles, and
coinsurance. You should also consider
contributions to accounts such as health
savings accounts (HSAs), flexible spending
arrangements (FSAs) or health
reimbursement accounts (HRAs) that help
you pay out-of-pocket expenses.
Can I use Coverage Examples to compare
plans?
Questions: Call (800)521-2227 or visit us at www.bcbstx.com/harlandclarke
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.cciio.cms.gov or call the number above to request a copy.
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